Plant Medicine Retreat
Application

Please note that the information you provide here will be protected and treated with the utmost confidentiality. These questions help us provide you with the safest environment and highest level of service we can. It is essential to the process that you answer with openness and honesty.

I. Personal Information

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Male or Female

II. General Information

Are you okay with living in a shared space? Our guesthouse has a kitchen, bathroom, river patio, and a large space for sleeping and storing personal items. We aim to ensure the utmost respect is given to our guests

III. Medical Information

Please select any physical health conditions you are experiencing right now or have experienced in the past

IV. PSYCHOLOGICAL / PSYCHIATRIC INFORMATION

Please select any conditions you are experiencing right now or have experienced in the past
Have you ever been hospitalized or received treatment/therapy for one of the above conditions?
Are you currently taking or have you ever been prescribed any medications for these condition(s)?

V. Trauma

VI. Addiction and Drug Use

How many alcoholic drinks do you normally consume each week?
Have you ever been diagnosed, treated, or self-identified as an alcoholic?
Have you ever used street- or recreational drugs (including Marijuana)?
Have you ever been diagnosed with, or treated for a drug or addiction?

VII. Medication

Are you allergic to any medication?
Are you currently taking or have you recently stopped taking (within the last month) anti­depressants?
Aside from anti­depressant medications, are you currently taking or have you recently stopped taking (within the past two months) any other prescription medications?
Are you currently taking or have you recently stopped taking (within the past month) any natural supplements, herbal medicines, or vitamins (including St. John wort, 5-HTP, Kava etc.)?

VIII. Emergency Contact

Please ensure you submit reliable contact information. We recommend you use the mobile communication device application "Whatsapp" for the communication median and your designated Emergency POC is also using that median.

IX. Terms and Agreements

 

Liability Release and Assumption of Risk

In consideration of being allowed to participate in any way in Zen Commando programs, its related events and/or activities, I fully understand, acknowledge, appreciate, and agree that: 

1. The risk of injury from the activities involved in this retreat, course, or program may be significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and, I hereby assert that I knowingly assume all of the inherent risks of the activity and take full responsibility for any and all damages, liabilities, losses, or expenses that I incur as a result of participation. 

3. I certify I am over 18 years of age and willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the staff immediately; and, 

4. I, for myself and on behalf of my heirs, assigns, personal representatives, and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS Zen Commando, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity (“Releases”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER, ARISING FROM THE NEGLIGENCE OF THE RELEASES OR OTHERWISE, to the fullest extent permitted by law. 

5. I grant permission to Zen Commando to use my photograph and/or any other record of my participation for any legitimate purpose. I understand that any and all photographs, motion pictures, recordings, and/or likenesses of me captured during Zen Commando Programming by Zen Commando become the sole property of Zen Commando. I grant the right, permission, and authority to Zen Commando to use my name and any such photographs, motion pictures, recordings, and/or likenesses for any legitimate purpose, including but not limited to promoting advertising, and marketing activities. 

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY AGREEING TO IT FREELY AND VOLUNTARILY WITHOUT INDUCEMENT

 

"The Camp Zen Commando Agreement"

I agree to attend and participate as best I can in all activities while at Camp Zen Commando. I agree to arrive on time, with a positive attitude, a sense of good humor, an open mind, and be ready to learn. I understand that I must do my best to cooperate with everyone in the course (instructors, staff, guests, students) and that this event is not a vacation.

 

All rules and regulations of Camp Zen Commando must be adhered to:

1. We are a substance and chemical-free environment that emphasizes a clean, respectful, and healthy lifestyle.

2. If I am uncomfortable with any physical aspect of the training (e.g., fitness exercises, hikes, yoga postures, survival situations, breathing exercises, etc. ) I will attend, listen, learn but may choose to not participate for my own reason.  

3. A major part of being at Camp Zen Commando is getting along with others and being open to new ideas and methods. I promise to be respectful of others' space, thoughts, actions, and viewpoints and not judge or discriminate. 

I understand participation is at my own risk and I am in good health and able to perform all tasks which may be asked of me while at Camp Zen Commando. Again, I understand that my physical participation is my responsibility and I am comfortable modifying any exercise or movement as needed and will communicate clearly and timely any issues I may have with the physical aspects of the course. I release my image and video for use by Zen Commando for marketing and social media purposes or I will ensure I am not in the photos or videos.  

Thanks for submitting!